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Predetermination

Preauthorizations and Predeterminations Explained

Preauthorizations and Predeterminations Explained

By Human Resources Communications on April 23, 2019

Under the UBC Extended Health plan, claims for medical equipment costing $5,000 or more require preauthorization prior to purchase.1 Under the UBC Dental Plan, any major treatment of $500 or more requires a predetermination prior to the treatment.2

However, if you find a recommended treatment plan or medical device to be cost-prohibitive, Sun Life will provide you with a preauthorization or predetermination free of charge.

Sun Life will first determine whether coverage is available to you, and if so, how much of the cost will be covered by your UBC Extended Health or Dental plan. This information will help you determine whether to move forward with the recommended treatment or purchase and could also be helpful if you decide to speak to your provider about an alternative treatment.

How do I request a medical services and equipment preauthorization or a dental predetermination?

Medical Services & Equipment Preauthorization

  1. Complete the appropriate Extended Health Plan Claim Form for your employee group, indicating “Preauthorization” on the form.
  2. For medical equipment and supplies, please make sure that the estimate includes the following information:
  • Date of purchase
  • Claimant’s name
  • Item description, including make and model name if available
  • Quantity
  • Price
  • Physician’s name
  • Proof of the portion paid by the province in which the service or medical equipment was obtained (if applicable)
  • Receipts must be legible and each expense must be listed separately and clearly indicated.
  • Cash register receipts are acceptable if the name of the product is included, a physician’s referral is attached, and/or the name of the patient is indicated on a signed claim form.
  • If the receipt is for a brace, please indicate the body part (e.g. left knee brace).
  1. Attach the recommendation from your physician (if required).
  2. Make copies of all the above and mail to the nearest Sun Life Claim Centre as indicated on page 2 of the claim form, or submit the estimate using the “send documents” feature on the Sun Life Mobile app.

Dental Predetermination

Many dental offices will electronically submit predetermination requests to Sun Life on your behalf. If your dental office prefers to submit predetermination requests on paper, have the dental office:

  1. Complete the appropriate Dental Plan Claim Form for your employee group, indicating “Predetermination” on the form.
  2. Ensure any x-rays or models are included with the request, if applicable.
  3. Have the dental office send this request to the nearest Sun Life Claim Centre as indicated on page 2 of the claim form.

Once Sun Life has reviewed the claim, they will mail a Claimant Statement to your home address. If you have registered for access to the Sun Life Plan Members’ website, you will be notified that the Claimant Statement is available for download.

References:

1 Preauthorization is required and it is a request for preapproval for reimbursement of medical services and equipment under the Extended Health benefits plan.

2 Predetermination is recommended and it is a fee estimate submitted to Sun Life. Sun Life will advise you and your dentist what portion of the fees will be reimbursed under the Dental plan.


Do you have questions? Contact the Health, Wellbeing & Benefits team at benefitsinfo@hr.ubc.ca.

Posted in Claims, Dental, Extended Health | Tagged Claims, coverage, dependents, preauthorization, Predetermination, Sun Life

Protect Yourself Against Unexpected Costs with a Dental Predetermination

By Human Resources Communications on May 13, 2016

dental predeterminationIf your dentist recommends expensive dental work for you or your dependents, you should always request a predetermination from your dentist before agreeing to the work.

A dental predetermination will confirm how much Sun Life will pay for your treatment.

A dental predetermination is a no-cost service available from Sun Life to assist you in:

  • Determining whether any or all of the dental procedures in the treatment plan are covered under UBC’s Dental plan,
  • Determining how much is paid by the UBC Dental plan and how must be paid out-of-pocket.

For those items which are not covered, speak with your dentist to determine alternative treatments or procedures.

Note that a predetermination is based on your dentist’s best estimate of how much the procedure will cost, and the final amount covered will be based on the procedure’s final cost.

Initiate a Dental Predetermination

Have your dental office complete an electronic dental claim form or a paper dental claim form for submission to Sun Life.

They should:

  • Ensure that the form is clearly marked as a predetermination request.
  • Include any supporting documentation, x-rays and/or models from the dental office with the claim form.
  • Submit the request to Sun Life Assurance Company of Canada:
    • PO Box 2010 Station Waterloo
      Waterloo, Ontario
      N2J 0A6

Don’t assume that coverage will be provided for any of the treatment plan – it’s your responsibility to request a predetermination prior to embarking on your treatment.

If you obtain dental services without a preauthorization, you are responsible for what the plan does not cover and in the case of major dental work this could be a significant and unexpected amount.

For further information on dental predeterminations, contact Sun Life at 1-800-361-6212 or 1-800-661-7334.

Posted in Dental | Tagged Predetermination

Why Get a Dental Predetermination?

Why Get a Dental Predetermination?

By Human Resources Communications on March 1, 2012

dental predeterminationIs your Dentist recommending expensive dental work for you and/or your family?  Always request a predetermination from your Dentist before getting the work done.

During a dental check-up, your dentist may recommend an extensive treatment plan for a dental issue.  Before making any decision, you need to find out how much of the cost will be covered by your UBC Dental plan and how much you will need to pay out-of-pocket.

Request a predetermination from your dentist

A dental predetermination is a no-cost service available from Sun Life to assist you in:

  • Determining whether any or all of the dental procedures in the treatment plan are covered under UBC’s Dental plan,
  • Determining how much is paid by the UBC Dental plan and how must be paid out-of-pocket, and
  • For those items which are not covered, speak with your dentist to determine alternative treatments or procedures.

To initiate a dental predetermination with your dental office:

  • Have your dental office complete either an electronic dental claim form or a paper dental claim form for submission to Sun Life.  Ensure that the form is clearly marked as a predetermination request.
  • Include any supporting documentation, x-rays and/or models from the dental office with the claim form.
  • If submitting the request by paper, remember to make a copy of the request and any supporting documentation prior to mailing to Sun Life.
  • Submit the request to Sun Life Assurance Company of Canada:

PO Box 2010 Station Waterloo
Waterloo, Ontario
N2J 0A6

Don’t assume that coverage will be provided for any of the treatment plan – it’s your responsibility to request a predetermination prior to embarking on your treatment.

For further information on dental predeterminations, contact Sun Life at 1-800-361-6212 or 1-800-661-7334.

Posted in Dental | Tagged Predetermination, Sun Life

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